Author + information
- aDivision of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- bDivision of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- cSection of Vascular Surgery, Department of General Surgery, University of Michigan Medical School, Ann Arbor, Michigan
- ↵∗Address for correspondence:
Dr. Daniel Alyesh, Cardiac Electrophysiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, Michigan 48109.
The United States leads the world in health care spending, but lags behind its peers in many quality measures (1,2). The transition for reimbursement from volume to value is inevitable, and disciplined innovation can drive it forward (3,4). Although policy decisions will shape the environment of this transition, execution of new health care models will come from care delivery systems. Successful organizations will adopt contemporary innovation techniques and draw from diverse perspectives, including patients and families. The prospect of executing such change will be challenging, but it presents a tremendous opportunity for shared organizational learning, as well as unique opportunities for fellows-in-training (FITs) and early career physicians (ECPs). We will present the University of Michigan Frankel Cardiovascular Center (CVC) Value Innovation Challenge (VIC) as an example of a successful initiative, detailing the landscape of value and innovation in health care from the perspective of FITs/ECPs and advancing patient- and family-centered care.
The goal of VIC was to promote a patient-centered, value-based care culture by empowering a community of trainees, faculty, staff, patients, and families at the CVC to propose changes to care. A 4-phase, progressive, pyramidal structure was developed using design thinking to funnel front-line ideas and interprofessional team-based proposals to CVC leaders (Figure 1) (5). The scope of proposed interventions varied from new care models to disease management programs and devices. The organizers designed the VIC to encourage engagement from community stakeholders through integration into employee workflow and prioritizing the patient experience.
Innovation Landscape in Health Care
Necessity is credited as being the mother of invention. Similarly, in the era of health reform, the number of centers for innovation in academic medical centers (AMCs) and community health centers has reached 67 total (6). This poses a unique opportunity for FIT/ECPs to serve in leadership roles and lend valuable perspective to innovation efforts, as evidenced by the leadership of FITs and ECPs in the ideation and design of the VIC.
The central question of innovation initiatives is “how do we do things differently and better?” This enquiry belies a complex network of considerations requiring equally complex solutions. Contemporary innovation health care methods combine experiential learning, perspective from those who deliver and experience care, and external opinions that challenge current paradigms (7). Achieving that combination of context and disruption can catalyze successful innovation.
During the VIC, we brought together those who experience care (patients and family) and deliver care (doctors, nurses, staff, and technicians) with broader university resources (engineering and administrative resources). Scheduling and coordination are significant challenges to assembling such a diverse coalition. Online crowd sourcing platforms, such as the one constructed for the VIC (Medstro, Cambridge, Massachusetts), create a virtual space to effectively harvest diverse perspectives (8).
Choosing the Right Innovation Structure
For medical professionals without formal training in change management, selecting the proper structure for an innovation program can be challenging. Medical centers are often large organizations, and even if a fraction of employees choose to submit ideas or proposals, sifting through submissions can be quite difficult. A variety of innovation models for distilling ideas exist. Some examples include:
• Ideation sessions: Short meetings where a provider group pitches ideas to innovation staff;
• Crowd-sourcing: Obtaining input from a large community, usually in an online space;
• Hack-a-thons: Usually, weekend events that bring together providers, engineers, and programmers to innovate; and
• Sandpit events: Interactive multiday workshops aimed at creating radical interventions (9).
The VIC was designed to capture elements of each model, while integrating into the patient experience and workflow of care providers.
Over a 2-month period, the VIC utilized virtual crowd-sourcing and in-person events to refine ideas into mature proposals. The online space minimized barriers to submission, maximized rapid feedback and team formation, and built on institutional memory. Crowd voting helped leaders identify high-need areas within the organization (Figure 1).
In-person events allowed important relationships to form for catalyzing change. An on-campus pitch event with external judges from diverse backgrounds (a medical educator, a health policy expert, a venture capitalist, and a chief executive officer of a large medical device company) challenged teams to refine their ideas and present them in a tangible, easily understandable format. The VIC generated 5 high-impact finalist projects from 56 submissions (Table 1). The winning team proposed a team-based enhanced mobility program using a novel device for post-surgical intensive care unit (ICU) patients.
Sustainability and Spread
As innovation efforts mature within the health care sector, they must move beyond idea generation programs to vehicles for successful implementation. Traditional clinical research can be expensive and focuses on high patient enrollment, statistical power, and longitudinal outcomes. In contrast, effective innovation uses the scientific method to rapidly prototype, test, and refine. Data can be generated over a period of days to weeks and often focuses on alternate metrics, such as statistical process control (i.e., control charts) to detect signals in the data without the large numbers required for traditional statistics (10). Improvement science methods, such as plan-do-study-act cycles and design thinking approaches, are useful tools for innovation teams to remain nimble (11,12).
In the case of the VIC, the winning team earned funding and 1 year of administrative, informatics, and implementation science support. The team is employing prototyping as well as rapid cycle improvement methods to construct a multidisciplinary post-operative mobility program. As an example of the value of a small-scale test, when the team used the mobility device with a single patient over a period of 1 week, they found that the patient participated in more mobility sessions over a longer of period time. Fewer staff members were required per session, which allowed therapists to see 1 to 2 additional patients daily. As the program scales up to include more ICU patients, the key performance metrics of ICU length of stay, ventilator days, and care utilization costs will be tracked.
Opportunities for Education
For FITs/ECPs looking to build careers in value and innovation, formal training in innovation techniques and improvement science should be sought to complement clinical training (13,14). Competency measures and curricular integration methods have been proposed for value-based health care in medical schools and graduate medical education, but similar recommendations for innovation techniques are not as readily available (15,16).
For FITs/ECPs to thrive in this new space, AMCs will need to create an environment that fosters quality improvement and innovation. At times, there is resistance to change based upon a belief that past successes are related to current practices (17). Although this sentiment is understandable, success for any health system will be significantly limited without fostering a culture of continuous improvement. FITs/ECPs participating in value-based innovation can help their organizations adopt new practices and adapt to a changing health care landscape. AMCs will need to value quality and innovation pursuits and consider creating faculty promotional tracks for these disciplines, beyond the traditional clinical and research tracks (9).
Advancing Patient and Family-Centered Care
Participation in hospital initiatives that enhance care value or pursue innovation are great opportunities to advance patient- and family-centered care (18). Critical to any successful innovation is the consumer perspective. Patient-centered interventions, such as home intravenous diuresis for heart failure patients, provide the opportunity to improve patient satisfaction and minimize unnecessary care (19). Collaborating with patients and families in designing and executing a new program, such as the VIC, strengthens an innovation by lending a valuable perspective that challenges care norms and closes a critical feedback loop.
Benchmarking With Peers
Shared learning and adaptation of existing interventions are clear avenues to better innovation. Researching best practices from programs such as University of California, San Francisco Caring Wisely, Costs of Care, and the Penn Center for Health Care Innovation allowed the VIC to draw validated ideas into a unique program that served its local needs (7,20). Notions of rapid testing and prototyping were borrowed from the practices of the Center for Health Care Innovation, and the concept of a broad value-based campaign was adapted from the University of California, San Francisco Caring Wisely program.
The most significant lesson was the tremendous power of crowdsourcing ideas for high-value interventions from those who directly deliver and experience care. High-impact ideas came from the front lines, and when they were connected to institutional experts, they unlocked remarkable untapped synergies. To engage the entire CVC in this program, community members were regularly involved in its design and execution. This practice advanced organizational culture by creating a connected and engaged community.
We believe the VIC could serve as a model for the way forward for health care organizations that seek to respond to a changing health care environment. Organizations can adapt this model to their local needs, and FITs/ECPs can readily serve as drivers in this process. The United States will continue to demand better health outcomes while reducing its world-leading costs. Despite a rapidly changing health policy context, the execution of value-based, patient-centered care rests squarely in the hands of providers and delivery organizations.
- David A. Asch, MD, MBA (, )
- Kevin B. Mahoney, MBA,
- Roy Rosin, MBA and
- Shivan J. Mehta, MD, MBA, MSHP
RESPONSE: Three Cheers for Everyone Else
Bill Joy, the computer scientist and cofounder of Sun Microsystems, is credited with a statement later known as Joy’s Law: “No matter who you are, most of the smartest people work for someone else” (1). It is an obvious point if you do the math. However, it remains a valuable reminder that the solutions identified by any group of people could almost certainly be made better if others were included. Just as valuable, although from another perspective, is recognition that there is no substitute for actually being there. That reminder explains why the highest ranking military commanders at headquarters, if they are any good, attend to the insights of the lowest ranking soldiers in the field. These 2 perspectives converge on a single point valuable even for C-suite health care executives at the top of their game. You can sit around a conference table and make thoughtful and considered decisions about how to improve your services, but you are likely to do much better if you spend a little extra time to include others and particularly those on the front lines. The happy corollary to Joy’s Law is that even if the smartest people work for someone else, it is not that hard to get a lot smarter.
Dr. Alyesh and colleagues report their approach to improving cardiovascular services at the University of Michigan. Their Value and Innovation Challenge crowd-sourced ideas and strategies distinguished their program by its inclusive reach. They emphasized engagement of not just the clinicians and staff operating at the point of care, but also the patients. They used accessible online processes to erode some of the barriers that limit engagement in complex organizations. They staged an in-person pitch session—a forcing function that provides focus and direction to teams, and allows interactive and encouraging judging and celebration. And although a number of promising ideas advanced toward implementation, they noted, “The most significant lesson was the tremendous power of crowdsourcing ideas for high value interventions from those who directly deliver and experience care.”
The team acknowledged borrowing from some of our experiences at the University of Pennsylvania, and indeed, our lessons are similar. 1) Even though the strategic direction of a large health system is set by its leaders, tactical approaches best originate in the field. 2) One of the greatest assets a large academic health system maintains is access to thousands of dedicated staff who entered the organization with a passion for improving care, but it is impossible for the leadership to give an audience to every member of the staff or evaluate every idea presented to them without some form of intermediating competitive process. 3) Health care is advantaged by an attribute rare in other industries: many of the most educated and empowered individuals are the ones directly connected to the customers. These have been among the guiding lessons at the Penn Center for Health Care Innovation, and now they are being confirmed at an increasing number of other organizations. In the end, although many recognize inclusion as an important social cause, each of these lessons speaks to the value of inclusion as an essential tactical strength.
- ↵Lakhani KR, Panetta JA. The principles of distributed innovation. Innovations 2007;Summer:97-112.
The authors thank Dr. Ran Lee, Dr. Lauren Heidemann, Nikki Taylor, and Diane Drago for their valuable contributions to this work, and Dr. Kim Eagle for mentoring and guiding this program.
- 2017 American College of Cardiology Foundation
- ↵Organisation for Economic Co-operation and Development. Health spending (indicator). Available at: https://data.oecd.org/healthres/health-spending.htm. Accessed September 8, 2017.
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